In the United States, over 40% of all surgical patients are older than 65 years of age.¹ As the age of our urological surgical patients continues to rise, there is an increased need for adequate preoperative evaluation to best predict patient outcomes and prevent patient morbidity and mortality. Advanced age carries a greater risk of postoperative complications, morbidity, and mortality, yet not everyone ages the same. We have all seen the healthy 70-year-old patient walk into our office, who runs 3 miles a week and volunteers at his local church; and then there is the 52-year-old patient who has trouble walking through our door, with a medical history and medication list that encompasses almost 2 pages of documentation.

As urologists, we employ multiple different methods to try to adequately evaluate patients preoperatively, including sending them for preadmission testing and the old-fashioned “eyeball test.” However, these methods are not always a great predictor of patient outcomes. More recently, patient “frailty” has emerged as a better indicator for mortality and morbidity than chronological age, or the Charlson Comorbidity Index. Despite this, frailty may be a concept you haven’t even heard of until now. An awareness of frailty and the associated risks for these adverse health outcomes can improve care for this vulnerable subset of patients, who we will be seeing more and more of in our offices.

Figure. Jamar Hydraulic Hand Dynamometer (cost $250.00 USD) for hand grip assessment.

Frailty has been defined as an age-related cumulative decline in multiple physiological systems, which is characterized by a vulnerability to adverse health outcomes and a low reserve for insult.¹ While multiple instruments exist in the literature, 3 main models have arisen to characterize how frailty develops and manifests. The Phenotype Model encompasses unintentional weight loss, self-reported exhaustion, weakness as measured by grip strength, slow walking speed, and low physical activity.² It was independently predictive of falls, worsening mobility, hospitalization, and death even after adjusting for comorbidities and social components predictive of mortality. The second model from the Canadian Study of Health and Aging (CSHA), the Frailty Index (FI), is calculated by quantifying the number of deficits present in an individual divided by the total number of deficits measured.³ These deficits include comorbidities, cognitive impairments, geriatric syndromes, and psychosocial risk factors. The FI score ranges from 0 to 1, with higher scores indicating greater degree of frailty. Lastly, the modified Frailty Index (mFI) consists of 11 variables from the CSHA Frailty Index that are available in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) database (see table). These variables are identifiable patient characteristics, which are able to be easily extricated via a simple history-taking and physical examination. Each criterion is equal to 1 point, so the index is calculated by adding all the criteria points available for your patient and dividing by the total, which is 11 points. The higher the score, the higher the frailty in your patient.

All these models have been examined to determine their relevance on surgical patient outcomes. Specifically, the mFI was utilized in 16 studies including 683,487 patients, of whom 65% were considered frail.⁴ This meta-analysis out of the American Journal of Surgery found that frail patients had higher rates of complications, wound complications, readmissions, discharge to skilled care, and mortality across multiple surgical subspecialties including urology. They concluded that patient frailty should be formally incorporated in the preoperative assessment of surgical patients and aid in surgical decision making. A prospective multi-institutional study assessed preoperative frailty in 14,530 elective surgery patients and stratified patient frailty into low, intermediate, and high risk.⁵ This study also included multiple surgical subspecialties, with urology encompassing the largest volume of cases at 24%. They found that increased frailty led to higher morbidity, readmission, and mortality. They also found that increased frailty led to more emergency room visits, increased length of hospital stays, and increased inpatient costs.

Despite the impact of frailty on postoperative outcomes as shown in the literature, there is a paucity of literature on frailty in urological sexual medicine and urological prosthetics. One retrospective study utilized the mFI in post-penile prosthesis implantation and found that it was not predictive of adverse outcomes, but did correlate with higher rates of postoperative Clavien-Dindo I-III complications.⁶ In a pilot study of patients undergoing inflatable penile prosthesis placement, Brennan et al analyzed patient grip strength to assess frailty.⁷ This group revealed that 77% of patients age 65 and older exhibited frailty, while 54% of patients younger than 65 also exhibited frailty. Frail patients in this group were at increased risk for prolonged recovery with pain and had more challenges with device manipulation/instruction. Notably, frailty did not correlate with increased postoperative complications. These are the only 2 articles in the literature for urological sexual medicine and frailty.

We believe that the grip strength test, if nothing else is used, is a great tool to assess penile prosthesis candidates, since those who may struggle with inflation or deflation of their device will likely have reduced hand strength. It is a relatively inexpensive device to purchase and can easily be used in an office setting with the patient in less than 3 minutes (see figure).

Jointly, NSQIP and the American Geriatrics Society proposed a best practice guideline stating that frailty should be formally assessed in the preoperative setting. However, frailty remains an underutilized prognostic indicator despite its ability to identify patients prior to surgery who may be at risk for postoperative complications or may require enhanced postoperative discharge planning and support. Specifically in the field of urological sexual medicine, the assessment of patient frailty can improve our ability to risk stratify patients and improve their postsurgical care. We should all be encouraged to adapt formal incorporation of preoperative frailty assessments in our patient population.